Is Negative Pressure Wound Therapy (NPWT) more effective than bolster dressings for promoting graft uptake and wound healing in patients who have undergone skin grafting procedures?

NPWT is Superior to Bolster Dressings for Skin Graft Uptake

Based on the highest quality evidence available, Negative Pressure Wound Therapy (NPWT) should be used over conventional bolster dressings for skin graft fixation, as it significantly improves graft take rates and reduces complications. A 2021 systematic review and meta-analysis of randomized controlled trials definitively demonstrates that NPWT yields improved percentage of graft take, reduces days from grafting to discharge, lowers the risk of re-operation, and does not increase adverse events compared to non-NPWT methods 1.

Evidence Supporting NPWT Superiority

Graft Take Rates

• NPWT consistently achieves higher graft survival rates across multiple studies. The meta-analysis of 10 randomized controlled trials involving 488 patients confirms NPWT's superiority in promoting graft integration 1.

• A 2019 retrospective analysis of 186 patients found that full-thickness skin grafts had significantly higher overall survival rates with NPWT compared to conventional mechanical dressing fixation (P < 0.01) 2.

• In radial forearm donor sites specifically, NPWT achieved 92% graft healing compared to 81% with conventional bolster and splinting at 4 weeks, with major graft loss occurring in only 10% of NPWT cases versus 28% with conventional management 3.

Mechanism of Benefit

• NPWT provides consistent, uniform pressure distribution and superior drainage compared to bolster dressings, which may induce inappropriate pressure points and increase wound complications 2.

• The negative pressure promotes graft adherence to the recipient bed, removes fluid collections that could prevent graft take, and enhances granulation tissue formation 4.

Optimal Pressure Settings

• Use 80 mmHg negative pressure for skin graft fixation. Subgroup analysis demonstrates improved graft take at 80 mmHg, while 125 mmHg showed no improvement over conventional methods 1.

Clinical Application Algorithm

When to Use NPWT Over Bolster Dressings:

• First-line for all skin grafts when resources permit, given the consistent superiority in outcomes 1.

• Mandatory consideration for:

  • Hand and upper extremity grafts (statistically significant benefit demonstrated) 2
  • Patients with peripheral arterial disease requiring foot wound grafting 5
  • Complicated chronic wounds resistant to conventional therapies 4
  • Patients with potential wound-healing problems 3

Practical Considerations

• Disposable NPWT systems offer a cost-effective alternative to conventional NPWT units while maintaining efficacy, with case reports demonstrating 100% graft uptake using lightweight disposable systems 5.

• NPWT reduces hospital length of stay by decreasing days from grafting to discharge 1.

Common Pitfalls to Avoid

• Do not use excessive negative pressure. Pressures above 80 mmHg do not improve outcomes and may be detrimental 1.

• While cost has historically been cited as a limitation for NPWT use 3, the reduction in re-operations, shorter hospital stays, and availability of disposable systems make this concern less relevant in modern practice 5, 1.

• Conventional bolster dressings create uneven pressure distribution that can compromise graft survival, particularly in anatomically complex areas like the hand 2.